Unkept Promises

“Your hands feel like velvet,” the 94-year-old woman told me as I pushed on her abdomen in the emergency department on a Friday night.

“That’s the nicest thing anyone’s said to me all day,” I told her.

“That’s pretty sad,” she said, and her abdomen quivered as she suppressed a laugh.

I walked out of the curtained room and briefly presented her findings to the resident on call. In return, he showed me her CT scan. A partial small bowel obstruction explained the pain and nausea. Her age meant that non-surgical management would be the best option: with “bowel rest,” hopefully the obstruction would resolve on its own. This would involve no eating, IV fluids, regular abdominal exams, and a tube inserted through her nose down to her stomach to suction out gastric secretions.

I went back to the woman’s room to tell her the plan.

“Not even water?” she said, looking dismayed. Only ice chips and not too many, I said. Or a moistened sponge to wet her lips, to help with the feeling of thirst.

“And I have to stay here overnight?” Yes. She needed to stay close to physicians, nurses, and CT scanners to monitor her progress. It was midnight. She looked at her daughter.

“She’s scared. She hasn’t been in the hospital for a very long time, and I can’t stay with her overnight.” her daughter explained.

I’d be here all night, I told them. “And since I’m seeing you now, I’ll also be the one who checks on you first thing in the morning.” This was routine; before rounds with the surgery team began at 6 a.m., the medical students quickly pre-rounded on the patients they had helped admit overnight. Check vitals, ask a few questions about bowel movements, palpate the abdomen. I resolved to add an extra few minutes if I could.

“That would make her feel so much better,” her daughter said, as she moistened her mother’s lips. “She doesn’t like to be somewhere where she doesn’t know anyone.” Well, now she knew me and my velvet hands. “I’ll see you in a few hours,” I told the woman, and she smiled with dry lips.

At half past midnight, I was pushing on another patient’s abdomen. He was morbidly obese, with a below-the-knee amputation from diabetic complications. Even with his nausea, vomiting, and pain in his lower right side, he had a greater frustration.

“I’ve been here for hours without even a sip of water.”

I explained that if there was even a slight chance that he would need surgery, it was important that he take nothing by mouth. Under anesthesia, if there was anything in his stomach, even water, it could come up and he could choke.

I gave him the compromise-that-was-not-really-a-compromise: the moistened sponge.

“The nurse said she would get that for me, and she left and never came back,” he retorted. There was little he could do except lie on the table and wait.

“Sir, I will personally get you that sponge as soon as I walk out of here,” said the resident.

“Can’t wait,” he scoffed. My eyes lingered over his 300-pound-frame barely contained by his johnnie, his stump of a leg, and his chest rising with labored breaths. The current offer for his discomfort seemed paltry, and I couldn’t blame him for his disdain.

The resident and I left the room, talked about appendicitis, looked at the CT scan and labs, ordered more medications, and paged anesthesia about an emergency appendectomy. Then the resident’s pager went off and she hurried out of the ED. Nothing left to do but write the consult note.

Patient’s chief complaint? That’s when I remembered the sponge.

“Did that help at all?” I asked, as I watched him moisten his chapped lips.

“Not really,” he said. “But can I have another anyway?”

After spending time on the wards, I am surprised by how easily promises slide from my lips. “I’ll see you in the morning.” “I’ll get you that sponge.” “The nurse should be by with your Tylenol soon.” Sometimes these words fall short of pure truth because the person issuing them is not the person physically fulfilling them. (How many other patients does the nurse have to see before she comes by with the Tylenol?) Sometimes the patient and I speak different dialects of language. (“Soon” in the emergency department for non-acute problems can extend into hours.)

Besides vaguenesses of language and dependence on third parties, promises may bend for other reasons. Some reasons are more pressing (a code), more immediate (another patient’s primary care doctor is finally on the line), or more political (the attending wants to round right now). Sometimes the original request is seen as trivial (he just got pain medication an hour ago) or redundant (he probably told his nurse anyway).

Sometimes we just forget.

One of the first and most repetitive themes I learned on my rotation was that surgeons hate fat. Heavy patients are difficult to wheel into the operating room and position on the table. Fat just beneath the skin takes longer to slice through during first incisions. Visceral fat--fat hugging the organs--makes visualization and execution difficult. Planes of dissection are warped, ducts and vessels are draped by a layer of glistening yellow, and organs are difficult to peel away from their sticky surroundings. Fat is dangerous.

At two in the morning, I watched as the surgical resident drove a trocar through that fat and into our patient’s right lower abdomen. A laparoscopic appendectomy is fairly straightforward: Make two or three incisions for the laparoscopic instruments, strip away surrounding fat and fascia to get a clear view of the appendix, separate it from the rest of the bowel, amputate it while being careful not to nick bowel or blood vessels, stitch up the remaining bowel and check for leaks, dunk the appendix into a small plastic net and remove it through the belly button, close the incisions. If things go according to plan, the procedure should take around two hours.

At the two-hour mark, the surgical residents were still stripping away fat. The appendix was inflamed and stubbornly stuck to the surrounding tissue. A clean view of the vestigial organ eluded the team. The senior resident began sniping at the junior resident, convinced that her camera maneuvers were the cause of the hold-up. The camera maneuvers grew more unsure and shaky as criticism was heaped upon them.

At the three-hour mark, the team had separated the appendix from the bowel. The senior resident threw a few stitches into the spot where he had cut away the appendix, but one went awry and now he wasn't sure if the bowel stump was completely closed. Over and over, the camera zoomed in and the residents pawed at the stump, straining to decide where best to place another stitch and if that next stitch would be the last. A bowel leak could be fatal.

"Can we turn off the music?" the senior resident bellowed, as the third Lady Gaga song of the night played from Pandora.

At 6 a.m., a call to the operating room from an irritated morning attending informed the team that they were missing rounds. Someone needed to break away from the OR and inform the day team of overnight events. The junior resident left, most likely under-prepared to present on these events, since she had been manning a camera for the last four hours.

The attending stepped in. Things went more smoothly but still slowly. We dunked an ugly large red appendix into a plastic net and struggled to pull it through the patient's belly button. It wouldn't fit.

By 8 a.m., my burning hatred of the appendix and all it stood for was muted only by my even more overwhelming desire to sleep. We closed the incisions. I wheeled the patient into the recovery area, inappropriately jealous that at least he had gotten to be unconscious for the ordeal. Then I staggered out of the hospital and staggered my way home and into bed.

Through a fog of half-sleep, I remembered the old woman who I hadn't been able to see that morning. And I finally realized why doctors hedge when a patient asks "when?" If it hadn't been a tricky appendectomy, it could have been another emergency department consult. It could have been an overworked intern asking me to do him a favor and help gather patients' vitals before rounds. It could have been an attending's last-minute teaching session. It could have been important. It could have been less important. But it would have broken my promise.

Why did I make a promise that I wasn't certain I could carry out? The easy answer is that I thought I could fulfill it. The more difficult answer was articulately explained by my sister Ilana Yurkiewicz on a recent episode of CBC's radio series White Coat, Black Art. She had a patient with a leg injury who grew increasingly upset that he wouldn't be able to return to work as soon as he wanted. She related, "I felt like I had to do something; I wanted to make it go away. So I kind of made him a false promise.... I think the reason I did it was just because I felt so compelled, I wanted to make his discomfort go away. And when all my stock lines were used, I said the first thing that came to mind--was that he'll get better soon, and I did not know that."

When we see patients, often they are living through some of the worst days of their lives. When treatment is slow, we use our words for more immediate reassurance. It worked in the short-term: the obese patient became less agitated when the resident promised to get him a sponge, and the old woman smiled when I said I would check on her. What I didn't see was when the woman awoke the next morning, alone, probably not smiling anymore. It's easier to remember the smile we see when we make the promise than to imagine the hurt we don't see when we break it.

Do we hide behind vague words for fear of not living up to specific ones? I've always hated "soon" but now I'm starting to understand it. It buys us leeway. It lowers expectations. It frustrates. But it's usually accurate.

I will undoubtedly make more promises. But maybe my next will come with a caveat: that maybe this isn't exactly a promise. Maybe this is what I want to say at midnight. Maybe this is what the patient wants to hear at midnight. But promises recede as the minutes tick by. Six hours is a lot of minutes. I would love to see you in the morning. I hope I can.

The views expressed are those of the author and are not necessarily those of Scientific American.

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